Florida Medicaid Provider Enrollment Application Guide

1 Florida Medicaid Provider Enrollment Application Guide Version | April 2021. Florida Medicaid Provider Enrollment Application Guide Version April 2021. Table of Contents 1 Purpose .. 1. 2 Contents .. 1. General Information .. 1. Enrollment Qualifications .. 1. Accuracy of Information .. 2. Notice Regarding Use of Social Security Number .. 2. Supporting Documentation requirements .. 2. Enrollment Process .. 2. 3 Before You Enroll .. 2. 4 Submitting a Provider Enrollment 3. Navigation .. 3. Welcome Statement .. 3. Enrollment Type .. 3. Enrollment Type 4. Application Tips .. 4. Request Type .. 5. Before You Continue .. 6. Identifying Information .. 6. Certification and Attestation Panel .. 7. License & More Identifying Information .. 7. Collaboration Agreement .. 8. Contact Information .. 8. Service Location .. 8. Mailing Address .. 9. Pay To Address .. 9. Home/Corp Office Address .. 9. Xref NPI .. 10. ATN Information .. 10. Member of the Following Groups.

2 11. Billing Agent Agreement .. 11. Owners and Operators .. 12. EFT Agreement .. 13. Applicant History .. 14. Supporting Documents .. 15. Certification .. 15. Application Confirmation .. 16. Verifying the Status of an Enrollment Application .. 16. ii Copyright 2021. All rights reserved. Florida Medicaid Provider Enrollment Application Guide Version April 2021. Application Status Descriptions .. 17. Submitting Corrections to a Pending Application .. 19. Maintaining Provider Information .. 20. Helpful Resources .. 20. iii Copyright 2021. All rights reserved. Florida Medicaid Provider Enrollment Application Guide Version April 2021. This page intentionally left blank. iv Copyright 2021. All rights reserved. Florida Medicaid Provider Enrollment Application Guide Version April 2021. 1 Purpose The Agency for Health Care Administration (Agency) and its fiscal agent, Gainwell Technologies (Gainwell), have created this comprehensive reference Guide to assist applicants with completing the Enrollment process using the Florida Medicaid online Enrollment wizard.

3 This Guide references and ties together Provider Enrollment -related information that is publicly available on the Florida Medicaid Web Portal, and provides guidance for completing the process for submission, uploading documentation, and verifying the status of a submitted Application . All public Web Portal resources can be accessed via Agency resources can be found on the Agency page at 2 Contents General Information Mailing Address Enrollment Qualifications Pay To Address Accuracy of Information Home / Corp Office Address Notice Regarding Use of Social Security Xref NPI. Number ATN Information (ATN is generated at this Supporting Documentation requirements time). Enrollment Process Member of the Following Groups Before You Enroll Billing Agent Agreement Submitting a Provider Enrollment Application Owners and Operators Welcome Statement EFT Agreement Enrollment Type Applicant History Enrollment Type Confirmation Supporting Documents Application Tips Certification Request Type Application Confirmation Before You Continue Verifying the Status of an Enrollment Application Identifying Information Application Status Descriptions Certification and Attestation Panel Submitting Corrections to a Pending License & More Identifying Information Application Collaboration Agreement Maintaining Provider Information Contact Information Helpful Resources Service Location General Information In order to receive Medicaid reimbursement, a Provider must be enrolled in Medicaid and meet all Provider requirements at the time the service is rendered.

4 Every entity that provides Medicaid services to recipients and all third-party software vendors offering services of any kind to providers must enroll as a Medicaid Provider . Enrollment Qualifications Providers must meet all Provider requirements and qualifications. Practices must be fully operational before they can be enrolled as Medicaid providers. General Enrollment requirements are covered in the Medicaid Provider General Handbook. Program specific qualifications for each Provider type are listed in the Coverage and Limitations Handbooks. All handbooks are available at 1. Copyright 2021. All rights reserved. Florida Medicaid Provider Enrollment Application Guide Version April 2021. Accuracy of Information All Enrollment statements or documents submitted to the Agency for Health Care Administration (Agency) or the Medicaid fiscal agent must be true and accurate. Filing of false information is sufficient cause for denial of an Enrollment Application or termination from Medicaid participation.

5 Notice Regarding Use of Social Security Number As a part of your Application for Enrollment as a Florida Medicaid Provider , all individuals listed as Owner(s) and Operator(s) are required to provide their social security number (SSN) to the Agency pursuant to 26 6109. Disclosure of your social security number is mandatory. Failure to provide your social security number will be a basis to refuse to enroll you as a Medicaid Provider . Your social security number will be used to secure the proper identification of persons for whom the Agency is responsible for making a return, statement, or other document in accordance with the Internal Revenue Code, and to assist in the administration of the Florida Medicaid program. Supporting Documentation requirements The Application process cannot be completed until all required documents as stipulated in the applicable Handbook sections, including an accurately completed Florida Medicaid Provider agreement and background screening, are received.

6 Applicants must include the Application Tracking Number (ATN) provided by the Online Enrollment Wizard when uploading supporting documents. Please visit the Enrollment Forms page via to obtain the forms needed for initial Enrollment . Applicants are encouraged to use the Interactive Enrollment Checklist tool to verify supporting documentation requirements prior to completing their online Application . Enrollment Process Most Provider Enrollment applications will go through the following process: 1. Applicant submits an Enrollment Application via the Florida Medicaid Web Portal Online Enrollment Wizard. 2. The Enrollment Application is evaluated based on the Enrollment rules. The Agency completes the credential verification process and site visit, when applicable. 3. The Enrollment Application is finalized. Provider receives a letter containing the final status, whether approved or denied. 4. Once the Enrollment status is Active, the Provider receives a Welcome Letter, and Florida Medicaid ID.

7 Full and limited enrolled providers will also receive a PIN Letter, that will be used to create a secure web portal account. 3 Before You Enroll Before initiating the Enrollment process, please follow the instructions listed below: 1. Review the Provider General Handbook, Chapter 2, for general Enrollment requirements . The handbook is located on the Agency's website at 2. Determine which Enrollment Type will be used. 3. Determine which Provider Type and Specialty will be used. View the Provider Type and Specialty to learn which qualifies for fully enrolled, limited enrolled, or order or referring Enrollment . 4. Refer to the Interactive Enrollment Checklist to identify Enrollment Application requirements based on Enrollment type, Application type, Provider type, and specialty, prior to starting the Application process. To access the Interactive Enrollment Checklist, visit mymedicaid- From the homepage, hover over the Provider Services tab, and click Enrollment .

8 Once at the Provider Enrollment page, look under the New Medicaid Providers section, and click Interactive Enrollment Checklist. 5. Before the Application can be submitted, all supporting documentation must be uploaded. 2. Copyright 2021. All rights reserved. Florida Medicaid Provider Enrollment Application Guide Version April 2021. 4 Submitting a Provider Enrollment Application The Florida Medicaid Provider Enrollment Application gathers information related to the applicant's eligibility to enroll in Florida Medicaid . Providers use this page to complete an Enrollment Application to become a participating Provider in the Florida Medicaid program. The following provides guidance for accurately reporting the elements of the Application . By logging into the secure Web Portal at , providers can complete their Enrollment Application by navigating to Provider Services tab and clicking on the Enrollment . The online Enrollment Application cannot be used if applying for Out of State Enrollment or Additional Location Codes.

9 Navigation Button Description New Application Click to create a new Application . Continue Application Click to continue an Application that was previously saved and assigned an ATN ( Application Tracking Number). Save and continue Click to save changes made to the current panel and proceed to the next. Note: Enrollment information is only temporarily stored in the Enrollment Wizard until you have reached the stage where an ATN. has been created. Previous Click to return to the previous panel. Exit Click to exit from the Online Enrollment Wizard. ? Click to access contextual page help. Delete Click to delete the selected row. Refresh session Click to extend the Online Enrollment Wizard session expiration time. Note: By default, the session will expire after 60 minutes. All unsaved information will be lost. Welcome Statement Upon launching the Florida Medicaid Enrollment Application Wizard, applicants will be greeted with a Welcome Statement panel, and will have the option to create a new Application or access on that was previously started.

10 Enrollment Type The Enrollment Type Determination panel will ask the applicant to choose the option that most accurately describes the reason they are applying to be a Medicaid Provider . The selection made on this panel will determine all of the steps that will follow in the Application . Provider must enroll as one of the following: 3. Copyright 2021. All rights reserved. Florida Medicaid Provider Enrollment Application Guide Version April 2021. Fully Enrolled allows providers to: Bill for services and receive payment directly from Medicaid . Participate in both the network of a Medicaid health plan as well as to bill for services and receive payment directly from Medicaid . Limited Enrolled allows providers to: Participate in the network of a Medicaid health plan. Ordering or Referring will allow providers to: Participate solely as a physician, or other professional practitioner, as a referring, ordering, certifying, or prescribing Provider of items or services for Medicaid recipients.